Aim: Nurses are the point of contact for patients admitted in hospital wards. Nurse's deal with all complaints of the patients, most common being pain. Hospitalised patients can suffer from pain due to various causes like post-operative, infection, malignancy, trauma, iatrogenic causes like i.v. cannulation, catheters etc. Proper management of pain in such patients improves patient experience and doctor-patient relationship. The knowledge and attitude of nurses regarding pain management affects the overall patient experience in hospital. We conducted a survey among nurses of tertiary care hospital (including government and private hospitals) in Pune regarding their knowledge, attitude and practices in pain management. Our questionnaire consisted of 20 questions relating to knowledge, attitude and practices of nurses in pain management. Material and Method: A survey was conducted among 248 nurses of tertiary care hospital (including government and private hospitals) in Pune regarding their knowledge (6 questions), attitude (5 questions) and practices (7 questions) in pain management using a questionnaire. Statistical Analysis: Questionnaire comprised all categorical answers hence descriptive statistics (percentage values) of all the individual categories was calculated. Results: Our survey revealed deficiency in nowledge, attitude and practices of nurses regarding basics of pain management, especially cancer pain and opioid use. Conclusion: This study has brought to light the deficiency in nursing curriculum or training regarding basics of pain management specifically cancer pain and opioid use.

Pain is one of the most common complaints of the patients admitted in hospital. A pain-free hospitalization lays the foundation for a long-term patient–doctor/hospital relationship. Nurses play a key role in the patient's experience of a hospital stay, as they are usually the point of contact for the patients admitted in hospital. Studies have been conducted regarding attitude and knowledge of nurses in pain management in other countries of the world.[1] They have been carried out in developed countries regarding the use of opioid by the nurses.[2] Studies evaluating knowledge of nurses regarding pain management has been conducted in Asian countries such as Hong Kong.[3] A study has been conducted among the Italian nurses regarding their knowledge and attitude for pain management in the patients of oncology department.[4] Surveys conducted among the nurses, which evaluate their knowledge and practices regarding pain management in India are almost nonexistent. This study was planned to evaluate knowledge, attitude, and practices of the nurses working in hospitals of India (especially, Pune City, Maharashtra).

Subject and Methods

A survey was conducted among 248 nurses working tertiary care government and private hospital in various departments like orthopedic, surgery, oncology. internal medicine, general surgery and gynecology using a 20 question based questionnaire. The nurses were randomly selected from tertiary care government as well as private hospitals of Pune. A survey form consisting of 20 questions was used. First 2 questions were about demographic and the rest 18 dealt with knowledge, attitude, and practices regarding pain management including opioid use. Test–retest reliability was found to be 0.8. Each nurse was given the questionnaire and asked to tick the best answer among the multiple-choice options. They were given adequate time to read and understand the questions and then submit their response.

Statistical analysis

Questionnaire comprised all categorical answers; hence, descriptive statistics (percentage values) of all the individual categories was calculated. Correct answer for each question was scored as 1 otherwise 0. Maximum scores on knowledge, attitude, and practices were 6, 5, and 7, respectively; thus, the total maximum score on the questionnaire was 18.

Results

The response to questions based on knowledge, attitude and practices of nurses were assessed as a group respectively using descriptive statistics. There was deficiency in all aspects of pain management (knowledge, attitude and practices) among the nurses especially opioid use and cancer pain management.

General knowledge regarding pain management

Q3) Do you know about the WHO pain ladder?

Q4) How many steps are there in WHO analgesic ladder?

Q5) Do you know the fifth vital sign

Q8) What are the side effects of nonsteroidal anti-inflammatory drug (NSAID)?

Q19) This drug can be used as an adjuvant to give pain relief?

Q20) Various nerve blocks can be used to give pain relief along with medications?

Attitude

Q6) Do you asses the patients regularly for pain?

Q7) Which pain scale do you normally use to assess pain?

Q11) Pain is natural after surgery, so patient must accept it without demanding relief.

Q14) Analgesics for postoperative pain should initially be given?

Q18) The most likely reason a patient would request increased doses of pain medication is?

Knowledge regarding opioid use and practices followed

Q9) Which injectable opioid do you normally use for pain relief?

Q10) Patient should be encouraged to endure as much pain as possible before using an opioid?

Q12) Morphine should be given to patient only in end of life period

Q13) What is the most important side effect of opioids, you watch out for in post-op patients?

Q16) Which of the following medication is considered the drug of choice for the treatment of prolonged modertate to severe pain in cancer patients?

Q17) If a cancer patients has been on Morphine for more than a month?

Discussion

Survey on general knowledge of nurses regarding pain management

There was a significant lack of awareness regarding the World Health Organization (WHO) analgesic ladder (54% of respondents). Though 46% of nurses were aware of the analgesic ladder, only 47% of them were aware that the analgesic ladder contains three steps. A total of 69% of respondents acknowledged that pain is the fifth vital sign. Majority (58.5%) were aware of the common side effects of NSAIDs, which was significant. Regarding postoperative pain, 67% correctly answered that pain is not natural after surgery and should not be accepted. Approximately 44% of the respondents were aware that steroids are used as adjuvant in pain relief. A total of 23% of nurses were aware of all the drugs (gabapentin, Tricyclic Antidepressant (TCA), steroid, and bisphosphonates) used as adjuvants in pain management, which was significant. A total of 81% of respondents were aware of the interventions in the form of nerve blocks, which were used for pain relief. Overall, the nurses had fair knowledge about basic pain management.

Survey on attitude of nurses regarding pain management

A total of 81% of the nurses assessed their patients for pain regularly. Majority of the nurses used some sort of pain scale for pain assessment (80%), whereas 20% of nurses did not use any pain scale for pain assessment. Although 59.6% of nurses were aware of the concept of round-the-clock medication for postoperative pain relief, 29.4% believed that postoperative analgesics should be given based on nurse's discretion. When a patient demands increased doses of pain medication, 65.1% of nurses believed that the patient would be having increased pain. Only 9.1% believed that such a request could be an attention-seeking behavior. Overall, the nurses' attitude toward pain assessment, management of postoperative pain was appropriate.

Survey on knowledge regarding opioid use and practices

A total of 79.6% of nurses used tramadol as an injectable opioid in wards. Majority (68%) believed that patients should endure as much pain as possible before starting opioids. Regarding morphine use, 63% were correct that morphine use is not to be restricted to end-of-life situation alone. Regarding the side effect of opioid, 44.7% were aware that respiratory depression is the most common side effect of opioid. A total of 66% of nurses were correct that morphine is the opioid of choice for cancer pain, but only 19% were aware that oral route is the most preferred route for analgesic administration in cancer patients. Approximately 31% believed that the dose of morphine is to be decreased, if cancer patient is taking it for more than a month, and 37% believed that its dose is to be adjusted as per pain intensity.

On analysis of survey, we found that significant lacunae were present among the nurses especially regarding opioid use. Their knowledge regarding management of postoperative pain was better as compared to opioid usage. Their knowledge regarding NSAID side effect was better as compared to opioid side effects. Most of the nurses were comfortable with intravenous tramadol, but were not aware of the use of oral morphine for cancer pain relief. Their knowledge regarding morphine use for cancer pain was inadequate.

This study has brought to light the deficiency in nursing curriculum or training regarding the basics of pain management, specifically cancer pain and opioid use. There is a gradual increase in the patients diagnosed with cancer in India; thus, there is an increase in the need for nurses trained in opioid use in these patients. Development of a training program targeting these deficiencies for the nurses in India will improve patient experiences and decrease stress on doctors dealing with these patients. A study by Gustafsson and Borglin [5] indicated that training of nurses in pain management improves their knowledge and attitudes regarding cancer pain.

Further studies can be conducted among the nurses of other hospitals in various cities of India, and a training program can be formulated based on the knowledge lacunae. The use of opioid also has an impact on the documentation work that has to be carried out by the nurses; this aspect of opioid use was not included in the survey.

Questionnaire for Nurses Knowledge, Attitude, and Practices in Pain Management

How many years have you been in clinical nursing?

A: None, B: 0–2, C: 2–5, D: >5

Do you work with admitted patients who have pain?

A: Always, B: Mostly, C: Sometimes, D: Never

Do you know about the WHO pain ladder?

A: Yes, B: No

How many steps are there in WHO analgesic ladder?

A: 1, B: 2, C: 3, D: None of the above

Do you know the fifth vital sign?

A: Yes, B: No

Do you assess the patients for pain regularly?

A: Yes, B: No

Which pain scale do you normally use to assess pain?

A: VAS/NRS, B: Wang Baker,

C: Other, D: None

What are the side effects of NSAIDs?

A: Acidity, B: Allergy,

C: Nephropathy, D: All of the above

Which injectable opioids do you normally use for pain relief?

A: Morphine, B: Tramadol,

C: Fortwin (pentazocine), D: Fentanyl

Patients should be encouraged to endure as much pain as possible before using an opioid.

A: True, B: False

Pain is natural after surgery, so patient must accept it without demanding relief.

A: True, B: False

Morphine should be given to patient only in end-of-life period

A: True, B: False

What is the most important side effect of opioids, you watch out for in post-op patients?

A: Respiratory depression, B: Allergy, C: Constipation, D: Addiction

Analgesics for postoperative pain should initially be given

A: Around the clock on a fixed schedule,

B: Only when the patient asks for the medication,

C: Only when the nurse determines that the patient has moderate or greater discomfort

The recommended route of administration of opioid analgesics for patients with persistent cancer-related pain is _____

A: Intravenous, B: Intramuscular,

C: Subcutaneous, D: Oral, E: Rectal

Which of the following analgesic medications is considered the drug of choice for the treatment of prolonged moderate-to-severe pain for cancer patients?

A: Codeine, B: Morphine, C: Fortwin, D: Tramadol

If a cancer patient has been on morphine for 1 month.

A: Stop morphine immediately

B: Decrease the dose slowly

C: Give only when he is having severe pain

D: Adjust the dose as per pain intensity

The most likely reason a patient with pain would request increased doses of pain medication is

A: The patient is experiencing increased pain

B: The patient is experiencing increased anxiety or depression

C: The patient is requesting more staff attention

D: The patient's requests are related to addiction

This drug can be used as an adjuvant to give pain relief to patient

A: Gabapentin, B: TCA, C: Steroids, D: Bisphosphonates, E: All

Various nerve blocks can be used to give pain relief along with medicines.